When Tom Boonen crashed heavily on Stage 5 of the 2011 Tour de France, he abandoned two days later, complaining of headache, dizziness, vomiting, and adverse reaction to colors and sounds. The same day he abandoned, Chris Horner crossed the finish line bloodied and in a daze, unaware that he’d crashed 30 minutes earlier and spent the final 25km chasing. At the 2013 Tour, Tony Martin crashed so heavily on the opening stage in Corsica that he passed out on his team bus, and had to be taken to the hospital on a stretcher.

In all three cases, the riders suffered concussions. And in two of the three cases — as with countless other incidents of concussion in cycling — they soldiered on and raced the following day. (Horner, who also broke his nose, did not continue.)

Head injuries are nothing new in cycling; modern helmets protect the skull, but do little to prevent concussion. But as increased attention is being paid to the lasting effects of concussion and traumatic brain injuries — and to chronic traumatic encephalopathy (CTE), a form of neurodegeneration that’s associated with repeated injuries to the brain — sports bodies are feeling the pressure.

While the NFL introduced its concussion protocol in 2009 and has adjusted it several times over the past seven years, professional cycling is behind, both in terms of a universal protocol but also in established monitoring of athletes in the days and weeks that follow a head injury.

One American doctor intends to change this. And he’s starting with data.

Tejay van Garderen and Chris Stockburger in Paris, in 2009.

Casting a wide net: A yearlong survey

Chris Stockburger’s name may not be known among most cycling fans, but it’s well known among nearly all U.S. professionals.

A former elite amateur with the USA Cycling development program, Stockburger came up through the ranks with riders like Tejay van Garderen and Brent Bookwalter (BMC Racing), Peter Stetina (Trek-Segafredo), and Alex Howes and Taylor Phinney (Cannondale-Drapac).

A Colorado native, Stockburger won the 2004 Tour de l’Abitibi, a seven-day, nine-stage UCI World Cup event. He raced for U.S. team Toyota-United in 2006, and rode the 2007 Amgen Tour of California as part of the U.S. national team before choosing to pursue a career in medicine, graduating with an MD from Washington University in St. Louis in 2013.

Since then, Stockburger has been in residency as an orthopedic surgeon at Barnes-Jewish Hospital in St. Louis. He still maintains his friendships from cycling — he and van Garderen were best man at each other’s wedding — and is all too aware of the injuries several of them have encountered.

In particular, both Phinney and Stetina suffered career-threatening leg injuries in 2014 and 2015, both due to course-safety issues, and both still bear the scars, and damage, years later. Prior to those incidents, Americans Saul Raisin, Scott Nydam, and Timmy Duggan all suffered traumatic brain injuries that affected their careers.

With the aid of Dr. Christopher McAndrew, an orthopedic trauma surgeon, and Amanda Spraggs-Hughes, director of clinical research, Stockburger is launching a yearlong study in 2017 into overuse and traumatic injuries that is both retrospective, investigating past injuries, while also prospective, tracking current injuries via a monthly email survey among professional and elite amateur racers.

A screenshot from Dr. Chris Stockburger’s survey of professional and elite road cyclists.

“The big picture is that this is something that there’s really no data on,” Stockburger said. “I think rider safety is becoming more and more a topic in pro cycling. The riders are worried about it, the teams worried about it, and in the last year, the governing bodies seem to be getting more involved in trying to improve rider safety. It’s hard to make decisions like that without any real data, The NFL has thousands of research articles into injury rates, and real data to back up safety policies. Cycling has two studies, and neither are particularly helpful. I’d like to help change that.”

The survey is open to competitive men and women who are road cyclists (minimum of Category 4) aged 18 and older; ability to complete the survey in English is required. It can be completed on a smartphone.

“I think it’s a great study to do,” van Garderen said. “There are little to no studies on the effects of cyclist’s crashes. I won’t name the guy, but I can remember a few years ago, at a race, a colleague of mine got a concussion, and he didn’t even tell his team, because he was afraid they would pull him out of the race, and he was on a contract year. So there he was, lining up for another race, a week after a concussion. That’s not safe for anyone, but that’s kind of the state we’re in. You ride hurt, but you don’t ride injured, the saying goes. But where is the line drawn?

Tejay van Garderen, on knees in red BMC Racing kit, said he’s crashed plenty of times, and broken a few helmets, but has never suffered a brain injury. Photo: Cor Vos.

“I’ve definitely broken a few helmets,” van Garderen continued. “They could have been mild concussions that went undocumented because they weren’t properly screened for. We have our team doctors, and they will do screenings, but there are really no guidelines as far as when you can get back to competition, the way there is in the NFL. With cycling, you get back on your bike and you’re back in the race.”

Stockburger is pursuing several avenues to drive enrollment in the study, such as through governing bodies, riders’ unions, and team management.

“The most important thing I want to emphasize is that my goal with the study is to get data on traumatic and overuse injuries, and get a sense for athletes concerns,” he said, adding that he hopes to provide all interested stakeholders with unbiased data to use for education and improved safety.

“Whether advocating for barriers in the last 3km, or requiring helmets during training, or requiring documentation of a standard return to training, and racing protocol after concussion, I don’t really know what the best targets are,” he said. “I also hope that a simple digital survey can be a proof of concept that an injury registry can be organized and helpful. With athletes’ training and racing decentralized, a self-reported digital survey may be the only feasible way to monitor injuries.”

Cycling’s concussion protocol: Whose decision is it?

Stockburger acknowledges that one of the biggest hurdles cycling faces when it comes to concussion protocol is its lack of stoppage time, and the inherent challenge of a rolling enclosure on a moving field of play. Pro cycling is a hardman’s game, and enduring through the pain is ingrained to the fabric of the sport. Assessing a serious injury on the fly is tricky, and most riders (and team managers) are hardwired to instinctively encourage pushing through the pain.

Current UCI protocol leaves the final decision as to whether a rider should continue in a race — a decision made either on the spot, during a race, or in the event of a stage race, in the hours after the finish — to the official race doctor, supplied by the race organizer.

The UCI requires race doctors to adhere to SCAT 3 (Standardized Assessment of Concussion) guidelines established at the fourth International Conference on Concussion in Sport, held in Zurich in November 2012. A standardized tool for evaluating injured athletes for concussion, the SCAT 3 calculates a score from a range of 22 symptoms.

At a stage race, where participating the following day in question, the decision is often made in tandem with team doctors, who administer their own tests.

A screenshot from Section 13 of the UCI’s 2015 Cycling Regulations, focusing on concussion and return to competition.

When Martin crashed at the 2013 Tour, Etixx-Quick-Step team doctor Helge Riepenhof, who is now team doctor at the Italian football club AS Roma, said the German rider had been evaluated using both the Sway Balance test and a blood test for the protein S100B, a well-accepted biomarker for traumatic brain injury.

“The final decision is always with the race doctor,” Riepenhof said. “There is a team protocol, you go through a few things, how they react, their vision, if they have had headaches, if they lost consciousness. You get points for it, and [with the Sway Balance test], if you’re above 80 points, you’re allowed to race. If you are below, you’re not allowed. Tony scored 82. It’s done straight away, if possible, and then again after 24 hours. We did it as soon as we were finished at the hospital.”

Riepenhof, who is an orthopedic and trauma surgeon, explained that Martin had also passed the S100B blood test, and that he then presented information from both screens to the Tour de France race doctor, employed by Tour organizers ASO.

“I gave them the hospital results, our test scores, which medications he is taking — it’s an open process,” he said. “If there was any risk at all, they wouldn’t let him ride.”

Eleven days after that crash, Martin won the Tour’s 33km individual time trial at Mont Saint-Michel.

A screenshot from the 2013 Sway Scoring Balance manual.

Relying on doctors provided by race organizers is an imperfect system, however, as doctors vary from event to event, and country to country.

In 2012, Medicine in Cycling, a group consisting of U.S. cycling doctors and other medical professionals, developed an in-race assessment “pocket card” with input from national governing bodies, athletes and other experts in the field. And while it’s a helpful tool, it’s not universally accepted or enforced by any governing body.

“Medicine in Cycling is a great group,” Stockburger said. “I attended the meeting in 2013 at USA Cycling soon after they had created the concussion protocol. I met Dr. Mark Greve out there and he was the first to point out the issues with the pocket card. While a great start and move in the right direction, it is a shortened, non-validated assessment based on more thorough assessments that have mediocre performance.”

Tony Martin was one of many riders to crash heavily on the opening stage of the 2013 Tour de France. He passed out on the Etixx-Quick-Step team bus after the stage, and was taken to the local hospital on a stretcher, but was cleared to race. Eleven days later he won the individual time trial.

Assessing what happens in the days and weeks that follow a head injury

Further, Stockburger said the issue of what happens to an athlete in the hours, days, and weeks after a concussion needs to be further addressed. It’s why he’s running a yearlong study, to find out what steps athletes take after injury, and what the effects are, both positive and negative.

In a recent interview, former world mountain-bike champion Roland Green told CyclingTips that he was never the same after a concussion at the 2003 Tour de Georgia, and that he believed improper steps taken immediately following the accident compromised his recovery.

“That night in Georgia I had a few drinks after the crash, which was a really bad idea, it thins your blood,” Green said. “The next day I hopped on a plane, with that reduced pressure in the cabin. That week I was at home, trying to train as if everything was normal, but it wasn’t, and I had a hard time completing a training ride, with vertigo and all that. And then the next weekend I went to Big Bear, with the high altitude, and I DNF’d. So I think I probably did a lot of damage in the week after the crash when I should have been resting. I probably needed someone to step in, like a health professional, and say hold on a second, you need to slow down.”

Cannondale-Drapac team doctor Prentice Steffen, an expert in emergency medicine and a member of the Medicine in Cycling group, developed a protocol for evaluating head injuries based on the Zurich conference. Steffen’s protocol prohibits riders from flying for three days after a head injury, due to changes in atmospheric pressure that can affect the blood flow in damaged parts of the brain — precisely the mistake Green made in 2003.

“Pro cycling is uniquely incentivized to keep riding into the next race, the next stage,” Stockburger said. “Other sports have weeks between games, or stoppage play, timeouts, doctors and coaches on the sidelines. In cycling, riders will crash, get hurt, finish the race, go back home, and get back on the trainer. Some of these issues are lifelong issues, so it’s not always worth pushing through or ignoring those symptoms.”

Stockburger acknowledges that he’s not going to solve the issues that surround concussions in cycling in a year — if ever. But he believes his study is an important first step.

“It’s a hard issue, and not one that anyone will fix overnight. Where does this study fit in? Are athletes getting assessed? Maybe in races they are, but at home they might be falling through the cracks. Are they getting graduated return to training plans? Maybe the WorldTour guys are getting great care, but the domestic guys may not be, and the local Category 1 racer may not even know what to watch for. These are some of the things I think we could find out.”

All competitive cyclists are encouraged to participate. The study will be conducted with an initial survey, which may take between five and 20 minutes; the initial survey investigates athletes’ perception of safety. It also asks questions regarding crashes and overuse injuries in the prior year. Athletes willing to enroll will then complete monthly surveys for one year, and will receive reminder emails to complete the monthly survey. The monthly survey may take one to 10 minutes, depending on the number of crashes or injuries required to describe. All information will stored on a secure HIPAA (medical privacy law) compliant database and will be de-identified for data analysis.

Tejay van Garderen, Chris Stockburger, and Peter Stetina at the 2005 junior world road championships in Austria. Stockburger finished 15th in the 23km time trial, the top American, 1:21 behind winner Marcel Kittel.